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D� ,n (d <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MAD ISDN.W 153707 State Plan I .Number. <br /> CONVENTIONAL ❑ ALTERATIVE (It assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER' ADDRESS OF PERMIT HOLDER: INSPECTION DATE' <br /> 355# ��anvI)fe f}ve. (O(/ <br /> BENOH MAHK jPerm efen <br /> rec.Pantl DESCRIBE IF DIFFERENT FROM PLAN: REF.PL ELEV.'. CST REF.P ELEV.'. <br /> LJ�,11 <br /> Name of Plnmbr, MP/MPRSWNor. County Sanitary Permit Number: <br /> SEPTIC T NK/ OLDING TANK: <br /> MANUFACTUR LIOUIDCAPACITY'. TANK INLETELEV.: TANK OUTLET ELEV.. WARINNG LABEL LOCKING COVER <br /> P IDED: PROVIDED. <br /> YES LINOBYEsBNO <br /> BEDDING VENT DIA.'. VENT MATL: HIGH WATER NUMBER OF FgAD. j/ PROPER ELLBUILDING' VENT TO FRESH <br /> 14 ALARM' EET FROM LIN ✓ / AIR INLET: <br /> ❑YES CHINC Cp O NEAREST 10 <br /> DOSING AMBER: <br /> MANUFACTURER BEDDING LIQUID CAPACITY: PUMP MODEL. PUMPISIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED'. PROVIDED <br /> ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL: BUILDING: VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET' <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST—III <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER- MATERIAL AND MARKING' <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> AL TEM: <br /> ,(IE,)Dl WIDT LENGTH' NO.OF DISTR.PIPE$PACING: CO ER INSIDE DIA.' #PITS: LIQUID <br /> f TRENCHES: / E C PIT /� DEPTH/ <br /> DIM SIONS <br /> 5a ; e --- <br /> VELDEPTH FILLDEPTH DISTR.PIPE DISTR.PIPE I DISTR,PIPE MATERIAL: OEDIISTR. NUMBER OF PROPERTY WELL'. BUILO(I�NG, VENT TO FRESH <br /> BELOW PPES AB V B�vER:r LEV. NLE ELEV.END'. C I` PI:` FEETFROM <br /> NEAREST�� <br /> I I /� u J'f <br /> MOUND SYSTEM: ' <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOIL COVER TEXTURE: PERMANENT MARKERS'. OBSERVATION WELLS, <br /> --=OIL <br /> _ ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL. SODDED'. SEEDED'. MULCHED: <br /> CENTER- EDGES'. <br /> ❑YES NO ❑YES ONO DYES ENO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH'. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE'. FILL DEPTH ABOVE COVER. <br /> TRENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.: ELEV: DIA.'. ELEV.' PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE'. HOLE SPACING DRILLED CORRECTLY- COVER MATERIAL' VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> LI YES ONO [-]YES ❑NO <br /> COMMENTS: PERMANENT MARKERS OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING: <br /> ^ / FEETFROM LINE. <br /> ❑YES LINO EYES ONO EF / <br /> "'f/i� <br /> rc,y�icls qrc� <br /> etch System on /"n �v Retain in county file for audit. <br /> Reverse Sid¢. (�'{ SIG ATU E At /, _ TITL ' <br /> Ari <br /> SBD-6710(R.06/88) Zrj \ <br />